Lalita Bhattacharjee Nutritionist National Food Policy Capacity Strengthening Programme Food and Agriculture Organization of the United Nations Bangladesh Presented on 2 July 2011 at the Training Workshop on “Food Security Concepts, Basic Facts and Measurement Issues” 25 June to 7 July 2011

            Introduction Nutrition through the life stages Dietary energy and nutritional requirements in: Infancy - birth to 1 year Childhood and adolescence Pregnancy and lactation Intergenerational effects Diet, energy and nutritional requirements in adulthood Nutrition during ageing and the elderly Operational Plan Indicators Life cycle approach Conclusion

    Diets in all cultural variety define to a large extent people’s health, growth and development Advances in research, expansion of knowledge in prevention and control of chronic diseases Return to the concept of basic life course – continuity of human life from fetus to old age Need to address both undernutrition and overnutrition

      Nutritional status is internationally recognized as an indicator of national development Nutrition is both an input and an output/come of the development process A well-nourished population is essential for productive work force and development ◦ people need food, health and care to be well-nourished Two processes: ◦ on the one hand food security policies ◦ on the other sustainable livelihoods, right to food and nutrition policies …with different partners The food, agriculture and health sectors is responsible for food and nutrition security

MATERNAL, CHILD AND HOUSEHOLD NUTRITION



Intra uterine growth retardation (IUGR)



Premature delivery of a normal growth for gestational age fetus



Overnutrition in utero



Intergenerational factors

    

Dietary, energy and nutritional requireme

nts All neonates typically lose some weight after birth Pre term infants are born with more extra cellular water than term infants and thus lose more weight than term infants Post natal loss should not be excessive. Loss of 15-20% of birth weight can lead to dehydration – inadequate fluid intake or tissue wasting from poor energy intake

What defines Infancy?

The first year of life.

Why are the nutrient needs of an infant so high?

Infants grow at accelerated rate: double birth weight by 6 months; triples by 12 months of age

2,50% 2,00% 1,50% 1,00% 0,50% 0,00% 5,00% 4,50% 4,00% 3,50% 3,00%

2,34% Exclusive breast fedding 1,90% Predominant Feeding Source:Arifeen et al, 2001 4,37% No breast feeding

New International Child Growth Standards for infants and young children released on 27 April 2006 ⇛ A community based study “The Multicentre Growth Reference Study (MGRS)’’ undertaken by WHO & United Nations University ⇛ More than 8000 children followed after every 3 months from Brazil, Ghana, India, Norway, Oman and USA

Monitoring infant growth:

◦ ◦ ◦  Infants not receiving adequate nutrition may have difficulty reaching milestones Failure to thrive (FTT): delayed in physical growth or size or does not gain enough weight Growth charts track physical development.

Head circumference, length, weight, and weight for length measures are used to assess growth

Infants have specific calorie, iron, and other nutrient needs.

     108 calories/kg of body weight for first 6 months 9.1 g protein/day first 6 months, 11 g/day second 6 months Fat should not be limited.

Vitamin K injection needed due to sterile gut Iron-enriched cereals/home based foods should be introduced at 6 months.

   ◦

Complementary foods

Not recommended to give any solid foods before 6 months

When to begin

 About 6 months of age  Iron and zinc stores depleted  Look for physical signs  Loss of extrusion reflex

Nutrient-dense foods

Solid foods should be introduced gradually to make sure child isn’t allergic or intolerant ◦ ◦ ◦ One new food per week Rice cereal is great first food: least allergy-causing Other grains, then vegetables, fruits over a period of months Homemade or store-bought baby food?

◦ Homemade is cheaper, but can also find high-quality store-bought foods without added sugar, salt, preservatives

     Implementation of comprehensive policies by the Government Full support for two years of breastfeeding or more Promotion of timely, adequate, safe and appropriate complementary feeding Guidance on IYCF in especially difficult circumstances, Legislation or suitable measures giving effect to the International Code

80 70 60 50 40 30 20 10 0 Year Africa Asia Bangladesh India Nepal Pakistan Sri Lanka

Country and yr H/A % < - 2 SD H/A % < - 3 SD W/H % < - 2 SD W/H % < - 3 SD W/A % < - 2SD W/A % < 3SD Bangladesh 2007 M F India 2005 -06 M F Nepal 2006 M F 43.7

42.7

48.1

40.0

49.0

49.6

16.5

15.8

23.7

23.4

19.5

20.8

18.4

16.5

20.5 19.1

12.9

12.3

3.3

2.5

6.8

6.1

3.1

2.2

39.9

42.1

41.9 43.1

37.5 39.7

11.4 12.1

15.3

16.4

10.1

11.2

Region

South Asia

Country Bangladesh India Pakistan

Africa

Benin Burkina Faso Ethiopia Mozambique Rwanda Tanzania Uganda Lowest 2nd

59 61 54 29 42 49 31 27 25 27

53 54 47 30 40 51 28 30 26 26 3rd 45 49 43 23 41 51 26 28 22 25 4th 43 39 37 20 39 45 19 24 20 19 Highest

30 26 26 10 22 37 9 14 12 12

Source: Gwatkin et al, Country Reports on HNP and Poverty: Socio-Economic Differences in Health, Nutrition, and Population, April 2007 Is Malnutrition in South Asia Really Worse than in Africa?

Quintile Lowest H/A % < - 2SD H/A % < 3 SD W/H % < 2 SD W/H % < 3 SD W/A % < 2SD W/A % < 3 SD 54.0

23.2

20.8

3.8

50.5

15.1

Second Middle 50.7

42.0

Fourth Highest 38.7

26.3

20.4

15.2

11.8

13.2

17.8

16.9

17.6

13.2

2.8

2.6

2.8

2.0

45.9

41.0

38.1

26.0

15.8

11.2

8.9

6.5

Age group Infants Children Boys Girls Boys Girls Boys Girls Category 0-6 mo 6-12 mo 1-3 y 4-6 y 7-9 y 10-12 y 10-12 y 13-15 y 13-15 y 16-17 y 16-17 y Body weight kg 5.4

8.4

12.9

18.1

25.1

34.3

35.0

47.6

46.6

55.4

52.1

Kcal/d 500 670 1060 1350 1690 2190 2010 2750 2330 3020 2440 Kcal/kg/d 92 80 82 75 67 64 57 58 50 55 47

    Association between low growth in childhood and increased risk of CHD, irrespective of size at birth Postnatal factors shaping disease risk Growth rates of infants in Bangladesh (most of whom had chronic IUUN and were breast fed, were similar to growth rates of breast fed infants in industrialized countries Catch up growth was limited and weight at 1 yr was a function of birth weight

     LBW babies have characteristic poor muscle but high fat preservation ( so called thin fat babies) This phenotype persists throughout post natal life and is associated with in childhood that is linked to ↑ risk of raised BP and disease increased central adiposity Association between LBW and high BP and BMI – importance of weight gain after birth Relative weight in adulthood and weight gain associated with ↑ risk of cancers Height serves partly as an indicator of socio economic and nutritional status in childhood (energy and protein intake)

    Secondary sexual characteristics emerge, with onset of menarche (periods) in girls and semenarche (production of semen) in boys Physical developments are accompanied by marked changes in psychological and emotional make up, characteristic of ‘teenage’ behaviour Adolescence begins approx 2 years earlier in girls than boys, with acceleration of growth of muscle in boys and deposition of adipose tissue in girls According to WHO, 10 to 18 y is the period of adolescence

    Adolescent boys experience rapid muscular growth and engage in more physical activities than girls so they need more energy foods Adolescent girls, because of menstruation, need more iron than boys Iron is essential for building and maintaining blood supplies ad giving the blood its red colour Girls should take more iron rich foods such as liver, egg yolk, lean meat, green leafy vegetables, dried beans, dried fruits and unpolished rice and whole wheat

Age group BW kg 10-12 y Boys Girls 13-15 y Boys Girls 16-17 y Boys Girls 34.3

35.0

47.6

46.6

55.4

52.1

Gain BW kg/y Basal loss mg/d 3.5

3.7

4.2

1.7

1.5

0.49

0.66

0.65

0.78

0.73

Blood volume mg/d Muscle mass Mg/d Store Mg/d 0.27

0.39

0.13

0.14

--- 0.13

0.15

0.06

0.05

--- 0.16

0.40

0.15

0.40

0.15

Blood loss Mg/d Total reqmt Mg/d ---- 0.28

--- 0.37

1.05

1.33

1.60

1.36

--- 0.42

1.37

1.30

 Development of risk factors  Tracking of risk factors (in terms of prevention)  Development of healthy/unhealthy habits that tend to stay throughout life (physical inactivity)  Older adolescents (habitual alcohol, tobacco use associated with risks of ↑ BP and related risks  Syndrome X ( physiological disturbances, hyper insulinemia, impaired GT, HT, ↑ TG and ↓ HDL

     Weight gain during pregnancy is an indicator of nutritional status of pregnant women A weight gain of 11 -13 kg during the pregnancy term is ideal According to various studies, weight gain during pregnancy in Bangladeshi mothers is only 7-9 kg indicative of poor nutritional status of the mother and poor growth of the fetus The fetus is born with LBW ( < 2.5kg) Over a third (36%) of babies in Bangladesh are born with LBW

Rate of tissue deposition Weight gain Protein deposited Fat deposited Average of 2 nd and 3 rd trimesters 1 st trimester (g/d) 2 nd trimester (g/d) 3 rd trimester (g/d) 17 0 5.2

60 1.3

18.9

375 kcal 310 kcal 54 5.1

16.9

12 kg increase 10 kg increase Total deposited (g) 12,000 597 3741 NIN/ICMR (2010) Nutrient requirements and RDA for Indians

     Lactation is the period when the mother feeds her baby through the breast. On an average 600-800 ml/d milk is produced by a nursing mother Approximately 1kcal of energy is needed to produce 1 ml of milk Malnutrition during pregnancy is likely to continue after birth of the baby if the mother is poorly nourished; a malnourished mother cannot breast her baby adequately Malnutrition affects the volume of milk produced if not its quality

Age group Man Woman Category Sedentary Moderate Heavy Sedentary Moderate Heavy Pregnant Lactation Body weight (kg) 60 60 60 55 55 55 55+ GWG 55 + WG Requirement Kcal/d kcal/kg/d 2320 39 2730 3490 1900 2230 2850 + 350 46 58 35 41 52 + 600 + 520

Women of reproductive age:

 The reproductive age in Bangladeshi mothers is considered as 15 to 44 years  CED in women of reproductive age is measured by height and BMI  Height < 145 cm and BMI < 18.5 kg/m² is indicative of chronic CED

0,50 0,25 0,00 -0,25 -0,50 -0,75 -1,00 -1,25 -1,50 -1,75 -2,00 0 3 Latin America and Caribbean Africa Asia 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60

Age (months)

Repositioning Nutrition, 2006

Mean height for age z-scores by age relative to the new WHO reference By region (0-59 months) 1.5

1.25

1 0.75

0.5

0.25

0 -0.25

-0.5

-0.75

-1 -1.25

-1.5

-1.75

-2 -2.25

-2.5

EURO EMRO AFRO PAHO SEARO

1 4 7 10 13 16 19 22 25 28 31 34

Age (months)

37 40 43 46 49 52 55 58 Source: Victora CG, et al. Worldwide timing of growth faltering: revisiting implications for interventions using the World Health Organization growth standards. Pediatrics, 2010 (Feb 15 Epub ahead of print)

Women's education 43% Health environm ent 19% Women's status 12% Contributions to reductions in child malnutrition, 1970-95 National food availabilit y 26% Source: Smith and Haddad 2000

    To what extent risk factors continue to influence development of CD To what extent will modifying such risk factors make a difference in the emergence of disease What is the role of risk factor reduction and modification in secondary prevention and the treatment of those with disease Adult phase of life –disease expressed, critical time for preventive reduction of risk factors and increasing effective treatment

       Most chronic diseases will be manifested in later stages of life Absolute benefits in changing risk factors and adopting health promoting behaviours (exercise and healthy diets) Maximize health by avoiding /delaying preventable disability Along with societal and disease transitions, major demographic shifts Older people defined above 60 y Average life expectancy increased from middle of last century Majority of elderly will be living in the developing world

         D isease E ating poorly T ooth loss/Mouth pain E conomic hardship R educed social contact M ultiple medicines I nvoluntary weight loss/gain N eeds assistance in self care E lder years above age 80

    Reduced need for calories More prone to disease due to lowered food intake, physical activity and resistance to infection Good food habits and regular exercise minimize the ill effects of ageing Need for more calcium, iron, zinc, VA and anti oxidants to prevent age related diseases Note: Variety of nutrient rich foods, match food intake with physical activity, eat food in many divided portions/d, avoid fried, salty and spicy foods and exercise regularly

• C

onfirms importance of first 2 years of life as a critical window within which child growth is most sensitive to environmentally modifiable factors

• M

onitoring length/height (in addition to weight) seems essential because faltering patterns are clearly different for HAZ and WAZ, and short stature is associated with deleterious long-term outcomes

• R

eveal a much greater problem of undernutrition during the first 6 months of life than previously understood (shorter “window of opportunity”) with possibly even higher levels of intrauterine growth retardation emphasizing the need for even greater need for prenatal and early-life interventions, including preventing low birth weight and promoting appropriate infant feeding practices

•

Suggests that BMI gain after 6 months of age increases adiposity but not height at 5years – hence potentially negative implications for NCDs in adulthood

Percent children LBW Slide courtesy of John Newman, SAR (2010) Source: WB World Development Indicators, Latest available data for each country, GDP PC PPP, constant int’l 2005 $

 GDP losses  2-3%  Leads to a >10% potential reduction in lifetime earnings for each malnourished individual  Malnutrition (stunting) in early years linked to a  4.6 cm loss of height in adolescence   0.7 grades loss of schooling 7 month delay in starting school

(Improved nutrition can be a driver of economic growth)

Repositioning Nutrition, 2006

Dietary factor Total fat Saturated fat PUFA Trans fatty acids Total CHO Free sugars Protein Cholesterol Na Cl Fruits and vegetables Total dietary fibre Non starch polysaccharides (NSP) Goal (% of total energy ) 15-30% < 10% 6-10% < 1% 55 -75% 10% 10-15% <300mg/d <5g/d at least 400 g/d From foods (40g/d) From foods (whole grains, F&V) 20g/d

  

Three child well being outcomes :

Mothers and children are well nourished (measured by rates of stunting and anemia) Mothers and children are protected from infection and disease

(measured by rates of malaria/illness, care seeking for treatment of diarrhea and ARI and immunization rates)

Mothers and children access essential health services (

measured by rate of skilled attendance at birth and antenatal coverage)

Objective ↓ in prevalence of LBW ( < 2.5 kg) ↓ in the prevalence of UW (WAZ < -2 Z scores ) in children < 5 y ↓ in prevalence of stunting (HAZ < -2 Z scores ↓ in prevalence of wasting (WHZ < -2 Z scores ) in children < 5 y ↓ in XN among pregnant women, lactating women and children aged 12 -59 mo) ↓ in the prevalence of anemia in < 5 y child, adolescents and in pregnant women Baseline 22% (SOWC, 2009) 41% (BDHS, 2007) 43% ( BDHS, 2007) 17 % (BDHS, 2007) 2.4 %; 2.7%, 0.04 % (IPHN/UNICEF/HKI, 2005) Children < 5 -48% Adolescent girls 30% Pregnant women 46% (National Anemia survey 2001 3) 34.6% (IDD survey 2005) ↓ in prevalence of I deficiency (UIE < 100 mcg/L of school age 6-12 y children) ↑ in rate of EBF in infants under < 6 mo ↑ in the rate of 6-24 mo children fed minimum acceptable diet 43% (BDHS, 2007) 42% (BDHS, 2007) Target 2016 15% 34% 38% 10% < 1% 23% 23% 50% 52%

Indicators Unit measurements (1) Prevalence of XN among < 5 y % of children 6-59 mo receiving VA % of VA supplementation in post partum women Rate of EBF in infants under < 6 mo (2) % children % children % PP women % children % children 6-23 mo fed minimum acceptable diet Prevalence of anemia among pregnant women Prevalence of anemia among children 6-59 mo Prevalence of iodine deficiency # of MOs trained in nutrition services delivery # CC workers trained in nutrition services delivery % of UHCs having a functional nutrition corner established % children % pregnant women % of children % of school age children No of MO in UHC No of HA, FWA and CHP # of Upazila Health Complexes Base line (with yr and data source) (3) 0.04% NSP 2006 88.3% BDHS 2007 19.5% BDHS 2007 43% BDHS 2007 41.5% BDHS 2007 46% National Survey 2001 48% National Survey 2001 34.6% IDD survey 2005 0 0 21 Mid 2014 (4) <1% 90% Projected target Mid 2016 (5) < 1% > 90% 50% > 90% 47% 48% 40% 40% 30% 578 (60%) 27,000 (60%) 120 (60%) 50% 52% 35% 35% 23% 964 (100%) 40,500 (100%) 200 (100 %)

     Unhealthy diets, physical inactivity and smoking are confirmed risk behaviours for chronic diseases Biological risk factors of HT, obesity and lipidemia are firmly established as risk factors for CHD, stroke and diabetes Nutrients and physical activity influence gene expression and may define susceptibility Major biological and behavioral risk factors emerge and act in early life and continue to have a negative impact throughout the life course Major biological factors can continue to affect the health of the next generation

     Globally, trends in the prevalence of many risk factors are upwards especially for obesity, physical inactivity and in the developing world particularly, smoking Selected interventions are effective but must extend beyond individual risk factors and continue throughout the life course Some preventative interventions early in life offer life-long benefits Improving diets and increasing levels and increasing levels of physical activity and older people will reduce chronic disease risks for death and disability Secondary prevention through diet and physical activity is a complementary strategy in retarding the progression of existing chronic diseases and decreasing mortality and the disease burden from such diseases

Determinants of Child Nutrition and Interventions to Address them Interventions - Infant and young child nutrition and treatment of severe undernutrition - Micronutrient supplementation & fortification - Hygiene practices - Agriculture & food security

- Health Systems - Soc. Protection/safety nets - Water & sanitation - Gender & Development - Girls’ Education -Climate change

- Poverty reduction & economic growth programs

-Governance, stewardship

capacities & management

-Trade & patents (&role of

private sector) - Conflict Resolution - Environmental Safeguards

Adapted from UNICEF 1990

Food/nutrient intake Access to food Maternal and child care practices INSTITUTIONS Health Water/ Sanitation Health services POLITICAL & IDEOLOGICAL FRAMEWORK ECONOMIC STRUCTURE RESOURCES ENVIRONMENT, TECHNOLOGY, PEOPLE Immediate causes

Nutrition specific interventions

S H O R T R O U T E S Underlying causes Basic causes

Nutrition sensitive interventions

L O N G R O U T E S